Hofmann BMC Medical Ethics (2017) 18:56
DOI 10.1186/s12910-017-0215-8
DEBATE
Limits to human enhancement: nature,
disease, therapy or betterment?
Bjørn Hofmann1,2
Open Access
Abstract
Background: New technologies facilitate the enhancement of a wide range of human dispositions, capacities, or
abilities. While it is argued that we need to set limits to human enhancement, it is unclear where we should find
resources to set such limits.
Discussion: Traditional routes for setting limits, such as referring to nature, the therapy-enhancement distinction,
and the health-disease distinction, turn out to have some shortcomings. However, upon closer scrutiny the concept
of enhancement is based on vague conceptions of what is to be enhanced. Explaining why it is better to become
older, stronger, and more intelligent presupposes a clear conception of goodness, which is seldom provided. In
particular, the qualitative better is frequently confused with the quantitative more. We may therefore not need
“external” measures for setting its limits – they are available in the concept of enhancement itself.
Summary: While there may be shortcomings in traditional sources of limit setting to human enhancement, such
as nature, therapy, and disease, such approaches may not be necessary. The specification-of-betterment problem
inherent in the conception of human enhancement itself provides means to restrict its unwarranted proliferation.
We only need to demand clear, sustainable, obtainable goals for enhancement that are based on evidence, and not
on lofty speculations, hypes, analogies, or weak associations. Human enhancements that specify what will become
better, and provide adequate evidence, are good and should be pursued. Others should not be accepted.
Keywords: Enhancement, Disease, Therapy, Naturalness, Nature, Limits
“Don't know what I want / But I know how to get
it.”Johnny Rotten
Background
Human enhancement (HE) is defined as “any kind of
genetic, biomedical, or pharmaceutical intervention
aimed at improving human dispositions, capacities, or
well-being, even if there is not pathology to be treated”
[1]. The topic has stirred vast and vivid debates, espe-
cially in the bioethics literature [2–6].
There seem to be two predominant camps in the de-
bate on HE: a permissive and a prohibitive [1]. While the
first camp sees few limitations to HE, the latter sees
many. While the permissive position provides arguments
from potential benefits, the prohibitive position refers to
Correspondence: b.m.hofmann@medisin.uio.no; bjoern.hofmann@ntnu.no
1Norwegian University of Science and Technology (NTNU), Gjøvik, Norway
2Centre for Medical Ethics, University of Oslo, Blindern, PO Box 1130, N-0318
Oslo, Norway
(religious and nonreligious) conceptions of sanctity, dig-
nity, and on the notion of “playing God.” In addition,
there is a restrictive camp [1], not being in principle
against enhancement, but which argues for limits from
concerns for justice and safety. However, there are few
specifications of how to limit HE in detail.
In this article I will investigate four specific routes to
limiting HE: Naturalness, disease, therapy, and better-
ment. The corresponding research questions are:
1. Do conceptions of naturalness provide resources to
set limits to HE?
2. Does the therapy-enhancement distinction provide
resources for setting such limits?
3. Does the concept of disease offer sources to limit
HE?
4. Does the concept of HE itself contain means for
setting limits?
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Hofmann BMC Medical Ethics (2017) 18:56
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While I will show that the first three questions do not
provide convincing answers, the latter may. However,
before I address these questions successively, I must ad-
dress the following question.
Why should there be limits to human enhancement?
There appear to be many motivations and arguments for
why we should try to limit human enhancement. Allow
me to mention a few of these:
Resources: HE has significant opportunity cost and
would drain resources from more pressing needs. This
of course relates to:
Justice: There are not enough resources available for
human enhancement for all, and to focus on human
enhancement under such conditions can enhance
disparity and injustice.
Humanity: Enhancement will change not only the
human condition, but humanity as such. One may lose
something charitable without knowing what will follow.
Uncertainty about benefits and harms: HE may have
unknown and potentially devastating consequences.
In this work I take it as a premise that HE needs to be
limited for some valid reason. At the end of the article, I
will return to this premise. Although the traditional ap-
proaches to set limits to enhancement may not be con-
vincing, they may not have to do such heavy work. The
limits to enhancement may be found in the conception
of enhancement itself. Investigating the weakness of the
arguments from naturalness, the therapy-enhancement
distinction, and the concept of disease, may provide as-
sets for exploring the self-limiting potential of human
enhancement.
Discussion
Naturalness: limits in nature
Several objections to HE and arguments for its limita-
tion are made with reference to human nature as a norm
[7]. The natural world has frequently been associated
with order and design (Harmonia Mundi), either teleo-
logical, mechanical, or cybernetic [8–10]. Correspond-
ingly, nature has been normative in many ways, e.g.,
epistemically, aesthetically, and morally. For example,
our knowledge of how to heal a broken leg, how to re-
store its appearance, and the impetus to do so is drawn
from the norm of a well-functioning leg of a being in its
natural habitat.
An explicit expression of the norm of nature can be
found in an editorial in JAMA from 1928: “The state-
ments that old age can be deferred have no more scien-
tific truth in them than the widely advertised promises
of rejuvenation. Senescence is a normal process of invo-
lution as necessary to the progress of life as is the
normal process of growth. It is intrinsic, inheritable,
fixed in the germ plasm through the action of all of
the forces of the Universe.” (Quoted from [11]). Most
cultures employ a distinction between “nature” and
“culture”; “man-made” and “nature-made” [12]. Ac-
cordingly, a common understanding of medicine is
that it works according to the norms of nature, as it
restores a given harmony.
Hence, nature may provide a prima facie norm for set-
ting limits to human enhancement. Let me briefly recap-
itulate some of these arguments.
Arguments from naturalness for limiting human
enhancement
One argument why society should not permanently en-
hance humans is that this would alter our common un-
derstanding of human excellence and flourishing in ways
that would undermine our social practices [13]. For ex-
ample, human enhancement would make us lose sight
“of why excellence is worth seeking at all, and hence
what excellence really is, and how we pursue it as hu-
man beings, not as artifacts” [4]. In particular, it
would alter the meaning of sports, as we would come
to honor technological innovation and not talent and
athletic achievement [14].
Another argument to limit enhancement is that human
nature is a complex reality and that enhancing one aspect
of it could undermine the excellence of the whole [13].
Accordingly, enhancing separate abilities would “disrupt
either the unity or the continuity of human nature” [15]
and compromise humanity [4], e.g., by diminishing our
humanity by decreasing our appreciation for beauty, ben-
evolence, and vulnerability [16]. A related concern is that
human enhancement would disturb a delicate balance in
nature resulting in unintended and potentially disastrous
consequences [17]. Alternatively, we obtain our enhance-
ment goal, but it appears to be counterproductive or
undermining something cherished [18, 19].
Yet another concern is that human enhancement
would make individuals stand outside the human spe-
cies, as “post-humans” [13]. Or that human enhance-
ment would violate some special feature of human
nature, such as basic dignity. As expressed by Eric Co-
hen: “All members of the human family – all living bod-
ies – have a human life, and therefore deserve the
respect that such membership commands” [20].
Further references to nature is made in claims “that
handicap and limitations are inherent to human condi-
tion, and should be endured as given by our own indi-
vidual fates” [7]. Such arguments sometimes are related
to human responsibility, i.e., that altering human nature
would give us a responsibility that we are not suited to
handle, and sometimes related to the (religious or non-
religious) metaphor of “playing God” [1, 6].
Hofmann BMC Medical Ethics (2017) 18:56
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The point here is not to review all arguments from hu-
man nature, but only to give a brief overview and a
backdrop for the counterarguments. Moreover, the argu-
ments are not always clear as to whether they address al-
tering humans, human nature, or nature in general.
Neither are the counterarguments. Nonetheless, the core
issue is that nature, of which human beings are an inte-
grated part, provides some standard for the human be-
ing, in terms of abilities, activities, aspirations, and
norms for treatment and restoration - and for setting
limits to enhancements.
Some counterarguments against the naturalness argument
A wide range of counterarguments have been presented
against these naturalness-based arguments for limiting
(or ban) HE. One much referred counterargument is
that human nature is normatively bidirectional, i.e., that
it can be both good and bad [21]. Evolution does not
guarantee goodness. “[T]he fact that natural selection
has operated on a trait does not ensure that the trait is
optimal” [5]. Evolution can be improved [22, 23], and
human nature may very well include culture and trad-
ition. The assumption that natural things and actions
are good, and that artificial things and actions are not
good is false and unwarranted [8, 24]. The core of this
line of argument is neatly summarized by Lewens in his
claim that nature “either constitutes an irrelevant pre-
amble to the important question of which features of
human reproduction should be preserved, or it consti-
tutes an objectionable allusion to some mythical and
morally loaded ‘human nature’ that might serve as an
ethical yardstick in debates of this sort” [21].
On the contrary, it is argued, there can be a moral im-
perative to change, improve, or reframe human nature,
using various forms of technology in the pursuit of some
other perfection or ideal [5]. To enhance ourselves “is not
eugenic but expresses our fundamental human nature: to
make rational decisions and to try to improve ourselves.
To be human is to strive to be better” [25]. Hence it is in
our human nature to enhance ourselves [26, 27] and to use
anthropotechnology to alter and ameliorate ourselves [28].
This line of thought has a range of sources. It can be
found in Pico de la Mirandola and Nietzsche claiming the
glory of humankind lies within an absence of a fixed na-
ture [8], and it can be traced back to Greek mythology
where humans are born without properties, stealing them
from others like Prometheus. It is by shaping nature we
form ourselves: our human nature. These thoughts may
also be connected to conceptions of nature as something
to overcome or to a duty to self-civilize with links back to
Erasmus and Plato [29]. Or in a Marxian remolding of na-
ture and man into a new social man [30].
Additionally it is argued that human nature is chan-
ging, and thus cannot provide a stable conception of
what is good. Due to mutations, there is no stable
species-typical genome to refer to as natural [31].
Humans do not have natures no more than biological
species [21]. Even more, humans have changed their
physical, biological, and microbiological nature exten-
sively. What we call “natural” means nothing more than
“usual,” which frequently changes: “For example, women
naturally menstruate and go through menopause in a
way that women do not naturally have in vitro
fertilization, tummy tucks, or breast augmentation or re-
duction. ‘Natural’ in this context means little more than
if not tinkered with, women usually do this” [32]. Ac-
cordingly, if we were not to tamper with nature, it would
bring us back before the Stone Age. Although some
would argue that we have tampered enough [33], we
“live in a world permeated by natural-artificial hybrids of
myriad varieties and stripes, and we may as well make
our peace with this ineluctable fact” [34]. As argued by
Barilan and Weintraub “[d]ividing the world between
nature and culture is artificial. This division is a cultural
construct by itself” [8].
Yet another line of counterargument points to the
empirically supported fact that there are many con-
ceptions of “nature” in the argument from nature to
limit HE. Let me therefore briefly review some no-
tions of nature and natural.
Many conceptions of nature and natural in the
enhancement debate
There are several conceptions of nature in play in the
HE debate [8]. Bess illustrates how human nature is con-
ceived of as an essential core, a blank slate, and as a
work-in-progress, and argues that none of them provide
solid ground for delimitation of enhancement [34].
Moreover, the Nuffield Council in a recent report has
identified five different conceptions of naturalness in
public and political debates about science, technology,
and medicine:
1. Neutral: a neutral/skeptical view that does not
equate naturalness with goodness.
2. Wisdom of nature: the idea that nature has found
the correct or best ways of doing things and should
not be “tampered” with.
3. Natural purpose: the idea that living things have
natural purpose, essence or functions which is
linked to what is good for them and which science
shouldn’t seek to change.
4. Disgust and monstrosity: a response of disgust,
revulsion or fear prompted by novel technologies.
5. God and religion: the idea that certain
technologies distort God’s creation or go
against the will of God [35].
Hofmann BMC Medical Ethics (2017) 18:56
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The four first conceptions of naturalness have been at
the front of the bioethics debates briefly reviewed above.
Furthermore, it has been shown that standard philo-
sophical conceptions of human-nature relationships,
such as Master, Steward, Partner, and Participant have
resonance in people, but that people see themselves as
“part of nature” and “responsible for nature” at the same
time [36]. This combined conception of naturalness is
not well covered in the bioethics debate.
Limits to the HE in nature debate and future directions
Although it is widely concluded that nature does not
provide norms for limiting HE, there are still concep-
tions of nature and naturalness that are not well ad-
dressed. For instance, Rousseau’s conception of human
nature as something we need to rediscover has gained
little attention in the bioethical debates. Heidegger’s
(and Stiegler’s) conception of humans being techno-
logical creatures, at the same time at home and not at
home within ourselves and with technology may also
provide relevant perspectives on nature and technology
facilitating critical reflection on HE. So may Kierke-
gaards conception of human nature as relation to our-
selves, mediated to our pre-connection to the other as
well as Spinoza’s distinction between natura naturans
(in process) and natura naturata (as fixed given). Arne
Næss’ conception of human nature as deeply connected
to the nature of our surroundings may do the same.
The point here is not to argue that these perspectives
provide means to set limits to HE. It is rather to indicate
that there are alternative conceptions of (human) nature
that have not been addressed in the literature, and that
may be worth pursuing. Anyhow, no knock down argu-
ment has been provided that the conception of nature
sets limits to HE, i.e., disagreement still exists and seems
warranted. Let me therefore move to the next candidate:
the therapy-enhancement distinction.
Therapy versus enhancement
HE goes beyond medicine as a healing enterprise, or as
expressed by Edmund Pellegrino: it “goes beyond the
ends of medicine as they traditionally have been held”
(Pellegrino 2004) as quoted in [37].
Coenen and co-workers make a fruitful distinction be-
tween restorative or preventive, non-enhancing interven-
tions (restitutio ad integrum), therapeutic enhancements
that allow a patient to perform better than before their
disease or accident, and non-therapeutic enhancements
which improve natural human abilities or to create new
abilities [38]. It is the latter where limits to HE have
been most heatedly debated.
One line of argument focuses on the use of the tech-
nology, and not the technology as such. Technology
used for treatment, rehabilitation, and restoration is
acceptable, but not for going beyond this. Therapy is
usually defined as the use of medical means to restore or
establish normal functioning of an organism [4, 39]. Ac-
cordingly, enhancement is to go beyond this warranted
basic provision of help [40], and the motives are entirely
different [41], providing a prima facie argument in favor
of limiting enhancement.
The therapy-enhancement distinction is also sup-
ported by arguments in professional ethics, where medi-
cine is defined in recuperative terms. Medicine is about
treatment, not enhancement [42], and is defined as “a
restorative practice aimed at the return to health” [43].
Using technology beyond this goal is to breach with its
professional ethos. As clearly expressed by Benditt:
“Medicine has always been about healing. The role of
physicians is not a matter of what they may have the
knowledge and skills to do, but about what constitutes
healing. Enhancing, though, is not healing. Therefore it
is not within the purview of medicine” [44].
Erik Malmquist supports the distinction between ther-
apy and enhancement (by showing that the continuum-
argument fails on three grounds) [45]. First, curing and
preventing disease is more fundamental to expand peo-
ple’s capacity to realize flourishing lives than enhance-
ment. Disease makes people incapacitated and unable to
pursue their happiness, and reduces autonomy in other
ways. Second, Malmquist points out that disease avoid-
ance can be more accurately specified than enhance-
ment. To remove the preconditions of Tay-Sachs or
cystic fibrosis is much easier specified than the precon-
ditions for enhancing traits, such as intelligence. Third,
disease avoidance tends to be more urgent than en-
hancement from the point of view of distributive justice.
Malmquist admits that these aspects may not provide a
knock down argument for a firm therapy-enhancement
distinction, but contends that they show that a con-
tinuum model is not an attractive alternative [45].
A sophisticated way to discriminate therapy and enhance-
ment has been based on distinguishing between compara-
tive and non-comparative harms. Not providing dietary
supplements during pregnancy (as a treatment) that could
prevent the resulting child from developing dyslexia would
result in counterfactual comparative harms [46] while not
enhancing the (cognitive) capacities of the embryo would
involve non-comparative harms, as it would not be the
same child that would come into existence.
According to these arguments the therapy-enhancement
distinction provides resources for setting limits to enhance-
ment. Let me briefly review some of the counterarguments
to see if this holds.
No sharp therapy-enhancement distinction
A frequently referred (pragmatic) counterargument is
that the therapy-enhancement distinction has long been
Hofmann BMC Medical Ethics (2017) 18:56
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surpassed in “standard-contemporary-medicine” which
includes “preventive medicine, palliative care, obstetrics,
sports medicine, plastic surgery, contraceptive devices,
fertility treatments, cosmetic dental procedures, and
much else” [47]. Accordingly, there is no better reason
to limit enhancement than to limit these and other types
of non-therapeutic activities.
Another argument against the treatment-enhancement
distinction is that it is a moving target. For one, therapy is
connected to the concepts such as “normality” or “health,”
which are “fishy” [48], vague [49], and relative [34, 50].
Variation in the population makes it difficult to define
pathology, and therefore also therapy. Second, the concept
of therapy is vague. The same intervention (with respect
to functioning) which in one case may be therapy may be
enhancement in another [47]. We use Ritalin to alter be-
havior or enhance school achievements. Growth hor-
mones are used to alter and enhance stature, and the
limits between them is blurred and socially contingent
[51] We also modify well-functioning organs (with bariat-
ric surgery) in order to treat Type II Diabetes (independ-
ent of weight loss) [52]. Moreover, what is considered as
treatment has changed considerably with time. Some
forms of assistive reproduction previously seen as en-
hancement are now considered to be treatments. This
vagueness in therapy is mirrored in the classification of in-
terventions. Vaccination can be seen as a form of preven-
tion, but also as an enhancement of the immune system
[47]. To distinguish between laser eye surgery and contact
lenses or glasses appears artificial. Moreover, it can be ar-
gued (as John Harris does) that even if the distinction be-
tween disease and enhancement can be established
clearly, it does not have a normative force for enhance-
ment. Enhancement is pursuit on its own merits.
Another counterargument endorses a welfarist con-
ception of medicine where therapy and enhancement
have the same goal, i.e., to improve the welfare of human
beings [1, 53, 54]. Any technology, be it therapeutic or
enhancing, is acceptable as long as it in sum improves
human welfare. So goes the argument. In line with this,
Savulescu claims that all “[t]reatments are enhance-
ments. Treatments are a subclass of enhancements”
[37]. Correspondingly, it is argued that “[m]edicine is in-
separable from human culture and creativity. Even when
it acts restoratively, its aim is the restoration of a cre-
ative and created life plan and values” [8].
Using cochlear implants as an analogy it can be argued
that we are already cyborgs, but also that future en-
hancements can be resisted (as the deaf community has
resisted cochlear implants) and that such enhancements
need extra measures in order to respect persons who for
various reasons do not want to be enhanced [55].
Another line of argument shows that most reasonable
interpretations of the concept of need supports publically
funded cognitive enhancement [56] as “normal simply is
not good enough anymore” [56]. The treatment impera-
tive is flexible.
In summary, while the arguments for limiting HE from
the therapy-enhancement distinction are not convincing,
no knock down counter-arguments are provided either.
There still is reasonable disagreement. In particular,
closer scrutiny of the concept of therapy, e.g., via its
etymological core, curing, healing, and attendance, may
provide fruitful sources for setting limits to HE. This is
beyond the scope of this article. Let me therefore move
to the next candidate: the disease-health distinction.
Disease as a barrier to enhancement
I have elsewhere argued that the concept of health does
not provide resources for setting limits to enhancement
(Hofmann B. Human enhancement: Enhancing health or
harnessing happiness? Submitted). On the contrary, hu-
man enhancement is based on and extends traditional
conceptions of health. I will therefore here concentrate
on the concept of disease, and whether it is suitable to
delimit enhancement.
Differentiating by disease
The boundaries of medicine are traditionally drawn at cur-
ing, preventing, and palliating disease. As succinctly
expressed by Benditt “medicine is concerned with disease,
which may be understood in terms of deviation from the
normal, which it is the role of medicine to restore. But,
the line of thought frequently continues, it is not the role
of medicine to go beyond this, to provide enhancements”
[44]. Disease calls for action in ways that health and en-
hancement does not. As stated by Lawrie Reznek 30 years
ago: “Judging that some condition is a disease commits
one to stamping it out. And judging that a condition is
not a disease commits one to preventing its medical
treatment” [57]. Disease is a deviance from the natural
condition of health and justifies interventions, which en-
hancement does not (with the same justification).
Differentiating on disease won’t do the trick
A series of arguments have been formed against this
traditional distinction between disease and enhance-
ment. One line of argument underscores that the con-
cept of disease alters with time and place [58], is vague
or fuzzy [59], difficult to define [60], and useless [61]. In-
creasingly, what was previously considered to be ex-
pected deterioration or “wear of life” is now labelled and
treated as disease. As explicitly spelled out by Morrison:
“the distinction between being healthy or having a dis-
ease (classifications based on the present) becomes
blurred as new categories of ‘pre-disease’ create a class
of ‘patients in waiting’ who have one or more detectable
molecular abnormalities and may or may not go on to
Hofmann BMC Medical Ethics (2017) 18:56
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develop symptomatic disease (a classification based on the
future)” [62]. “Standards of normalcy serve as scales of a
second order of diagnosis and monitoring, but they do not
define states of health and disease. A ‘normal’ red blood
cell count does not make a person ‘normal’. It is a nor-
malcy only within the context of specific clinical ques-
tions” [8]. Hence, so goes the argument, the disease-health
distinction cannot provide clear limits to enhancement.
As already alluded to, the welfarist conception of medi-
cine also undermines the distinction between health and
disease. According to Schermer, “it is not self-evident that
enhancement falls outside the goals of medicine, if we
agree that medicine should aim at well-being, quality of
life, or fulfilling vital goals” [42]. In the same wain Savu-
lescu tells us that, “[i]t is not [disease] which is important.
People often trade length of life for non-health related
well-being. Non-disease [states] may prevent us from lead-
ing the best life” [63]. In another work Savulescu argues
that “on all concepts of disease, the mutually exclusive dis-
tinction between treatment and enhancement is a false
one. … Diseases are a subclass of disabilities” [37]. Treat-
ing disease or compensating disabilities are just specific
forms of human enhancement.
However, a general rejection of disease as delimiting
concept of human enhancement may be too hasty and
superficial, as there are distinct theories of disease which
may offer different means for setting limits to enhance-
ment. Let me therefore briefly investigate three trad-
itional conceptions of disease, i.e., the normativistic,
naturalistic, and hybrid conception of disease.
Normativistic conceptions of disease Normativistic
conceptions of disease see disease as given by social and
cultural norms and not by nature [64]. What falls under
the concept of disease is flexible. One strand of normati-
vistic conceptions of disease (and health) can be traced
back to Nietzsche’s reflections in The gay science where
he claims that: “the more we put aside the dogma of
‘the equality of men’, the more must the … the normal
course of an illness be abandoned by our physicians.
Only then would the time have come to reflect on the
health and sickness of the soul, and to find the peculiar
virtue of each man in the health of his soul: in one per-
son’s case this health could, of course, look like the op-
posite of health in another person” [65]. Hence, the
normativistic conception of disease is unsuitable to set
limits to enhancement. Anything can in principle be-
come disease and thus the subject to medical attention.
Naturalistic conceptions of disease Naturalistic con-
ceptions of disease are considered to offer more resist-
ance to enhancement. Disease is defined in terms of
dysfunction or subnormal functioning [6, 66–69]. To
interfere with “species-typical functioning” is therefore
to reach beyond the justified sphere of medicine and
health care [6] (p.72).
However, removing (and avoiding) disease is conceived
of as (a subclass of) enhancing health, especially by welfar-
ists. Nonetheless, the welfarist approach does not bite on
naturalists clinging to species-typical functioning [67, 70,
71] as they do not subscribe to its premises.
Against this it can be argued that what is species-
typical or normal is not necessarily desirable: a reduced
protection of ozone would make white people vulnerable
to radiation and skin cancer and “whites might have dis-
abilities relative to blacks even though their functioning
was quite species typical or normal” [72]. Others would
argue that setting limits to “normal” and providing cut-
off values for “natural functioning” involves some evalu-
ation of “the good life,” and hence, of moral values. Vari-
ous forms of interventions that change the reference
class or alter normal functioning of a species [67] also
alters disease. To this it can be responded that radiation
exposure is not species typical and that thresholds are
not related to human values [67, 73].
While offering some substantial resistance for those
believing in biological norms, there is still reasonable
disagreement on whether naturalistic conceptions of dis-
ease provide measures to limit enhancement. Even more,
HE can challenge naturalistic conceptions of disease.
Hybrid conceptions of disease Hybrid conceptions of
disease see disease as having both naturalistic and nor-
mativistic elements. As such that could provide a com-
bination of naturalistic objections with more normative
reasons to limit enhancement. However, the normativis-
tic element, such as “harmful”, [74, 75] does not provide
powerful limit-setting measures. It can definitely be
harmful for a person not to have a high intelligence if
the person lives in a context where intelligence is (the
only thing) meriting. Moreover, the naturalistic element
of hybrid conceptions of disease only bites if you sub-
scribe to a biologic axiology.
Altogether the (naturalistic) conception of disease pro-
vides more assets for limiting HE than the naturalness-
argument and the therapy-enhancement distinction, espe-
cially if you are based in a biological axiology. However, in
an anthropocentric axiology, one would argue that we
need a morally normative element in order to be action
guiding. Biology is not sufficient. Moreover, it can be ar-
gued (pragmatically) that so far the concept of disease has
not been able to restrict health care activities.1 Health care
goals go way beyond handling disease already, and thus,
will not be suitable to limit human enhancement.
I have now briefly reviewed the traditional sources of
setting limits to HE, i.e., naturalness, the therapy-
enhancement distinction. Although they still have poten-
tials for providing limits to HE, so far, reasonable
Hofmann BMC Medical Ethics (2017) 18:56
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disagreements still exist. Hence, they do not provide knock
down arguments for limiting HE.
However, this does not mean that there are no means
to set limits to HE. Limits to enhancement may be
found in the concept of enhancement itself, or more
precisely, in the limited power of deducing goodness
from enhancement.
Enhancement and the notion of good
One main challenge with the literature promoting en-
hancement is that it is unclear what “enhancement”
means. As Bess points out, the meaning of enhancement
varies along three dimensions:
Differences of degree: tweaking vs. transmogrifying
Differences of mode: boosting vs. adding vs. radical
remolding
Differences of relative effect: competitive advantage
vs. intrinsic benefit [34].
According to Bess, this makes the use of the term en-
hancement slippery and controversial. In particular,
there tends to be a confusion of better with more [34].
Confusing better with more
One example of this is the argument that it is better for
humanity to have people with higher rather than lower IQ
scores. “On average, people with a high IQ have better
jobs, eat healthier, are less superstitious, and are less likely
to be either violent or the victims of violence” [76]. Or
here in the words of Dan Brock: “But suppose that a trait
such as memory could be genetically enhanced so that
everyone could have a “photographic” memory, or that
everyone could be brought up to what is now the high
end of the normal range of intelligence” [77].
As Bess points out, there seems to be a confusion be-
tween the quantitative conception of enhancement, i.e.,
as augmentation, and the evaluative conception, i.e., as
improvement [34]. However, as pointed out by Parens
and others, more is not always better [78, 79]. As with
aging, it is far from obvious that living longer is better.
Previous reflections on the relationship between more
and better seem to be ignored. Titonus obtained eternal
life, but found it meaningless. Virginia Wolf’s Orlando
lived for 400 years but found it toiling. In Douglas Ad-
ams’ Hitchhiker’s Guide to the Galaxy, Wobagger lives
eternal, but is miserable.
Michael Hauskeller points out that it is very hard to an-
swer in advance and out of context what is better. The rea-
son for this is that all, or, at least, most traits suggested by
enhancement enthusiasts – physical strength, intelligence,
emotional stability, long-livedness, predispositions to feel
happy, etc. – are complex traits that interact with other
traits of a person in unforeseeable ways [80]. It is difficult
to determine what a good human being is and which lives
are “better” than normal. The reason why it is so difficult to
tell what is a good human being, compared to, say, a coffee
machine, is that as human beings “we do not have a definite
purpose” [80]. Although, thinking is part of human charac-
teristics and it is considered to be bad for human beings to
be prevented from thinking, it does not follow that thinking
more is better [80].
The apparent tendency amongst the proponents of HE to
associate more with better (more strength and endurance,
more intelligence, longer lives) seems analogous with the
strong cognitive associations between morality and health
as well as sinfulness and disease [81] (pp. 208–209). In this,
it is argued that ethics seems to go along with the hypes
and hopes of emerging technologies far too easily [82–84].
Contrary to the complaint about a “status quo bias” [22],
there tends to be a corresponding “change bias.”
Apparently, this problem is acknowledged. As pointed
out by Earp and colleagues “more is not always better,
and sometimes less is more” [85]. To underscore this
they introduce the notion of “diminishment as enhance-
ment.” By defending a welfarist conception of enhance-
ment they believe to have solved the problem. However,
to include less in the quantitative measure (in addition
to more) does not provide content to the qualitative con-
ception of goodness.
To define goodness in terms of individual persons’
wellbeing may not do the trick either. Savulescu defines
human enhancement as “improvement of the person’s
life. The improvement is some change in state of the
person—biological or psychological—which is good.
Which changes are good depends on the value we are
seeking to promote or maximize. In the context of hu-
man enhancement, the value in question is the goodness
of a person’s life, that is, his/her well-being” [37]. There
are many reasons why conceiving enhancement in terms
of increased wellbeing may not be convincing. First and
foremost, what maximizes the wellbeing of the individ-
ual may undermine the wellbeing for groups of individ-
uals and for society at large. Relativizing wellbeing to
individuals may not make the world a better place. The
argument only has traction if you subscribe to a specific
philosophical position, which, despite great progress, still
is far from all-encompassing. Second, it still is an em-
pirical premise that enhancing certain traits (either by
augmentation or attenuation) would in fact increase
wellbeing (or other forms of goodness), which is not
proven to be true. No doubt, social media have in-
creased the number of social interconnections, but
whether it has improved our wellbeing is an open
question. With Schramme one can argue: “The im-
provement of human life can only be considered a
collective duty if we know that the results would
really constitute an improvement” [70].
Hofmann BMC Medical Ethics (2017) 18:56
Page 8 of 11
Hence, more work is needed to show that something
is an enhancement, and explaining enhancement in
terms of augmentation (or diminution) appears not to
do the trick.
Forward in all directions
Accordingly, the argument for HE without a more elab-
orate conception of betterment (than individual well-
being) is not convincing, as better is different from more
and individual wellbeing is complexly entangled in social
involvedness. Defining enhancement in terms of in-
creased individual wellbeing is hardly helpful, as well-
being appears to be as broad and contestable a concept
as health. The argument from change or argumentum
ad novitatem does not work either. Even if we need to
change, it is not obvious that HE is for the good.
To counter this problem it is argued that opponents of
HE are subject to a status-quo-bias [22, 23, 86]. As
clearly stated by Kahane and Savulescu: “This is, per-
haps, the best diagnosis for the status quo bias that in-
fects so many protagonists in the debate – since we
don’t know what would be better, we should remain
where we are” [23]. However, this critique does not bite
because it turns the question on its head. What is asked
is rather this: If you argue that we should go forward,
you should show that doing so makes life better. If you
claim to improve something, then you should give con-
vincing arguments that the change that you suggest ac-
tually is better.
Hence, the better clause of HE provides an ingrained
measure for limit-setting to HE, or more precicely, to
guide human enhancement. When you say we should
enhance X because it will make the world better, it is fair
to ask why the world becomes a better place from en-
hancing X. Arguing that enhancement (in terms of
change) is better in and of itself is a(n opposite) equiva-
lent to the status-quo-bias, i.e., a “progress bias.”
Proponents of HE argue vigorously that there are ob-
jective values to show what betterment is. They suggest
that “only radical relativist or nihilist could hold that
there are no robust values that can guide enhancement.
For example, one basic element of morality is willingness
in certain situations to make selfsacrificial decisions for
the benefit of others. Extreme pervasive and persistent
selfishness is a vice” [23]. However, the problem with
this statement is that it provides a very poor compass
for human enhancement. In fact it offers an extremely
flimsy and meager moral guidance. First, we still need to
decide whether an action is self-sacrificial (or egocen-
tric). Second, the fact that an action is self-sacrificial ob-
viously does not make it good.
The specification of betterment problem does not van-
ish by making it relative to whatever people find good.
Kahane and Savulescu argue that: “For pretty much
every objection to biomedical enhancement, it is possible
to reply: ‘If what worries you about enhancement is X,
then why shouldn’t we try to enhance X?’ For example, if
you worry that human enhancement will threaten our
openness to the unbidden, solidarity with others, or au-
tonomy, then how can you object to biomedical inter-
ventions aimed to increase people’s openness to the
unbidden, solidarity, or their autonomous capacities?”
[23] Be this as it may, the problem of assuring the con-
nection between HE and betterment (of X) still remains.
Another challenge is that when we enhance humans
our value system may change. Hence, what was good
yesterday may not be good today. Without a clear, sus-
tainable, and well argued for goal, HE is meaningless.
Accordingly, HE contains the sources for limitation (or
guidance) in itself. It is not necessary to set “external”
limits in terms of naturalness, therapy, or disease. We
only need to demand clear, sustainable, obtainable goals
that are based on evidence, and not lofty speculations,
hypes or weak associations.
Objections
In this article I have argued that the traditional resources
for setting limits to HE, such as naturalness, therapy,
and disease, are not convincing. However, I have found
that the lack of specification of betterment inherent in
the conception of HE itself provides means to set limits.
Human enhancements that specify what becomes better
and where adequate evidence that this will happen is
provided are good and should be pursued. Others should
be limited.
Although the traditional conceptions of disease, ther-
apy, and naturalness may not offer effective limits to hu-
man enhancements, alternative or modified versions of
such concepts may still do so. To clarify or modify con-
cepts of disease, therapy, or nature (or their contrary
concepts health, enhancement, and nature) warrants a
separate investigation.
Correspondingly, it may be argued that valid limits are
to be found elsewhere, e.g., conceptions of authenticity
[34] or in moral psychology. One may argue, for example,
that there are moral psychological propensities supporting
opposition to enhancement [1] or that various forms of
conservativism can do the job [2, 27]. Moreover, limits to
HE could also be analyzed in terms of concepts such as
“natural purpose” [35], medicalization [87], and others.
Strong intuitions and emotions (repugnance) [2, 88–90]
also seem to set limits.
The premise of the article is that we need to set limits
to HE. As acknowledged, some think that this premise is
false. We need HE to improve the world is their argu-
ment. To debate the premise is beyond the scope of this
article. However, implicitly I have argued that the prem-
ise may not be relevant when demanding that HE should
Hofmann BMC Medical Ethics (2017) 18:56
Page 9 of 11
only be pursued when it contains a clear, sustainable,
and obtainable conception of betterment. There may be
no need to limit HE. Demanding clearly formulated, em-
pirically evident, obtainable and sustainable goals of HE
may make it self-limiting.
The very endeavor of setting limits may be identified as
being “conservative” or “restrictive” [2] in contrast to be-
ing “permissive” (or “bioliberal”). Such labelling seems to
have more rhetoric than analytical function. By appealing
to the clarification of betterment, and endorsing HE that
can provide clear, sustainable, obtainable goals for HE, I
do not subscribe to any of these labels. They tend to be
limiting rather than promoting to a fruitful debate. More-
over, as indicated, the need to set (external) limits may not
be as prominent, if we pay more attention to the guiding
power of the specification of betterment.
The debate on human enhancement is characterized
by licentious speculations where the proponents advo-
cate research and implementation, with caution advised
(only if at all) for concerns about safety and justice, and
critics see the prospect of HE as an assault on humanity
as such. Both tend to rely on unwarranted preconditions
(biological determinism) and strong beliefs [91].
It is also important to point out that it is far from obvious
that the counterarguments against setting limits to HE
hold. On the contrary, I think that several of them are
flawed. E.g., the argument against the therapy-enhancement
distinction of Guibilini [48] are based on false premises.
However, the point in this article has not been to enter into
the particular arguments, but rather to illustrate that some
of the traditional limit setting resources are not convincing,
and to argue that this limit-setting may not be needed, as
the goal setting of HE is overly unclear. By learning from
the arguments about naturalness, the therapy-enhancement
distinction, and disease, we should demand the same clarity
and precision of the concept of enhancement as its propo-
nents require from the concepts of nature, therapy, and dis-
ease in order to have any limiting or directing function. If it
is not clearer what is meant by enhancement than what is
meant by nature, therapy, or disease, no more should we
pursue the former than it can be limited by the latter.
I agree with Bess that the concept of enhancement is
oftentimes played off against concepts like “natural,”
“therapeutics,” “normal,” “healthy,” and “disease” as
“these concepts form the necessary basis on which most
discussions of medicine, technology, and human nature
tend to take place” [34]. However, we need to move on
in the enhancement debate and more precisely discuss
the improvement part of HE: what exactly is improved
and why is it better?
One may also ask about the limiting power of the spe-
cification problem of HE. Will demanding specifications
of betterment be sufficient to counter the speculations,
hypes, and high hopes of the proponents and to govern
HE? One reason why the approach may be effective is
that it is easier to specify what is bad than what is good,
as there tends to be a basic asymmetry in ethics [92].
After all, it may be easier to define what is disease than
what is health and what is treatment than enhancement.
Hence, the conceptual and moral challenges may temper
the hypes and hopes in a fruitful way – especially if we
are able to avoid the confusion of better with more.
Conclusion
In this article I have investigated the traditional resources
for restricting human enhancement, such as the concepts
of naturalness, therapy, and disease. These do not seem to
do the job. However, the article shows that the concept of
enhancement is feeble in defining what is to be enhanced,
i.e., goodness. The qualitative better is frequently confused
with the quantitative more. Accordingly, the lack of speci-
fication of betterment inherent in the conception of HE
itself provides means to restrict its unwarranted prolifera-
tion as well as guiding its fruitful implementation. We
may therefore not need “external” measures for setting
limits in terms of naturalness, therapy, or disease. We only
need to demand clear, sustainable, obtainable goals for hu-
man enhancement that are based on evidence, and not
lofty speculations, hypes, analogies, or weak associations.
Human enhancements that specify how humans will be-
come better, and where adequate evidence that this will
happen is provided, are good and should be pursued.
Others should be restricted.
Endnotes
1In fact even authors in the naturalistic camp can
claim that the concepts of health and disease are not
suitable to delimit the tasks of health care [67].
Abbreviations
HE: Human enhancement
Acknowledgements
I am thankful to Laurens Landeweerd for inspiring input to parts of this
article. I am also most thankful to the reviewers (Anna Pacholczyk and
David Lawrence) and the Editor who in an admirable way have pointed
to weaknesses in previous drafts and constructively have suggested and
spurred improvements.
Funding
Part of this research has been funded by the Norwegian Financial
Mechanism 2009–2014 and the Ministry of Education, Youth and Sports
under Project Contract no. MSMT-28477/2014, Project no. 7F14236.
Availability of data and materials
Not applicable.
Author’s contribution
I am the sole author of this article and have drafted, written, revised, and
submitted the manuscript myself.
Ethics approval and consent to participate
Not applicable.
Hofmann BMC Medical Ethics (2017) 18:56
Page 10 of 11
Consent for publication
Not applicable.
No patients are involved in this study and no ethical approval and consent
from patients/ participants is necessary (or possible).
Competing interests
I do not have any financial or other material, professional, or scholarly
relationships that involve the area under discussion in this manuscript, i.e., I
have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Received: 1 March 2017 Accepted: 4 October 2017
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